12 Csom Part 3

C.S.O.M.
:
Mastoidectomy
Dr. Vishal Sharma
Schwartze’s Cortical
Mastoidectomy
Middle ear cleft (Right)
Cortical Mastoidectomy
Boundaries of cavity
• Superior: Dural or Tegmen plate
• Anterior: Posterior wall of external auditory canal
• Inferior: Digastric ridge
• Posterior: Sigmoid sinus plate
• Medially: Lateral semicircular canal

Normal temporal bone (right)
Indications
1. Coalescent mastoiditis & Masked mastoiditis
2. CSOM T.T.D. active refractory to antibiotics
3. Secretory otitis media refractory to antibiotics
4. Approach to:
 Endolymphatic sac surgery
 Facial nerve decompression
 Vestibulo-cochlear nerve section
 Translabyrinthine approach for C.P. angle
 Cochlear implant surgery
 Combined approach tympanoplasty
Antiseptic dressing
Draping
Infiltration with Lignocaine
Marking of incision
Wilde’s post-aural incision
Incision deepened till periosteum
Musculo-periosteal flap elevated
Bezold’s abscess
Aspiration of pus
Drainage of abscess
Drainage of abscess
Corical mastoidectomy begun
Exposure of mastoid antrum
Widening of aditus
Aditus widened
Final Cavity (right)
Final Cavity (left)
Drain put in mastoid cavity
Mastoid dressing
Healed post-aural scar
Treatment for
Attico-antral disease
Medical Treatment
Topical ear drops + frequent suction clearance
Indications:
1. Early disease with shallow retraction pocket
2. Only hearing ear with cholesteatoma
3. Elderly patients
4. Pts who are not fit for surgery under G.A.
5. Pts who can regularly come for follow up
Surgical Treatment
Canal Wall down:
• Attico-antrostomy
• Modified Radical Mastoidectomy (MRM)
• Radical Mastoidectomy
Canal Wall up:
• Combined Approach Tympanoplasty (CAT)

Mac Ewan’s triangle
Canal Wall Up Mastoidectomy
Canal Wall Down Mastoidectomy
Middle ear cleft
Attico-antrostomy
Modified Radical
Mastoidectomy
Pre-operative Anatomy
Cortical Mastoidectomy done
Modified Radical Mastoidectomy
Surgical Steps
• Perform cortical mastoidectomy
• Lower facial ridge & break facial bridge
• Remove cholesteatoma & granulations from

mastoid air cells & middle ear cavity
• Preserve healthy mucosa, T.M. remnant & ossicles
• Mastoid cavity & E.A.C. become a single cavity

seperated by middle ear cavity
• Perform tympanoplasty. Do concho-meatoplasty.
Antiseptic dressing
Draping
Infiltration
Infiltration
Marking of incision
End-aural incision
Temporalis fascia graft
Periosteum incised
Periosteal flap elevated
Mastoid cortex exposed
Posterior canal wall incision
Posterior canal wall vascular strip
Vascular strip retracted laterally
Drill cuts on mastoid cortex
Corical mastoidectomy begun
Cholesteatoma in mastoid cavity
Exposure of mastoid antrum
Widening of aditus
Aditus widened
Cortical mastoidectomy cavity
Facial ridge lowering started
Breaking of facial bridge
Elevation of tympanomeatal flap
Elevation of tympanomeatal flap
Removal of cholesteatoma over lateral SCC
Retrofacial & labyrinthine cells removed
Incudo-stapedial joint separated
Malleus head nipped off
Tensor tympani tendon cut
Cholesteatoma removal from attic
Exposure of sinus tympani
ET orifice plugged with malleus head
MRM cavity
MRM cavity (ossicles preserved)
Sites of facial nerve injury
Korner’s meatoplasty incision
Flap elevated
Conchal cartilage cut
Flap sutured posteriorly
Healed Concho-meatoplasty
Post-aural incision closed
Radical
Mastoidectomy
Radical Mastoidectomy
Surgical Steps
• Perform cortical mastoidectomy. Lower facial ridge
& break facial bridge. Remove cholesteatoma &
granulations from mastoid air cells & middle ear.
• Remove normal middle ear mucosa, T.M. remnant &

ossicles (except stapes footplate).
• Close Eustachian tube opening. No tympanoplasty

done. Concho-meatoplasty performed.
• Mastoid, E.A.C. & middle ear become single cavity.

Indications
1. CSOM attico-antral disease with
 Intra-cranial complication
 Recurrence after modified radical mastoidectomy
 Profound sensori-neural hearing loss (?)
2. Limited malignancy of middle ear
3. Glomus jugulare
4. Osteomyelitis of temporal bone

Causes of
discharging mastoid
cavity
1. Inadequate concho-meatoplasty
2. Recurrence of cholesteatoma
3. Residual cholesteatoma: facial ridge, facial
bridge, anterior + posterior buttress, mastoid tip,
sinus tympani, anterior epitympanum
4. Persistent infection: petrositis, T.B., sinusitis
5. Persistent allergy
6. Retained foreign body: cotton ball
7. Persistent extra-dural abscess
8. Wrong indication
Combined Approach
Tympanoplasty
Surgical Steps
1. Cortical Mastoidectomy
2. Anterior tympanotomy: via tympano-meatal
flap
3. Posterior tympanotomy: via facial recess
4. Tympanoplasty
Anterior Tympanotomy
Posterior Tympanotomy
Tympanoplasty
Thank You

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C.S.O.M.

• Superior: Dural or Tegmen plate

• Anterior: Posterior wall of external auditory canal

• Inferior: Digastric ridge

• Posterior: Sigmoid sinus plate

• Medially: Lateral semicircular canal

• Modified Radical Mastoidectomy (MRM)

Canal Wall up:

• Combined Approach Tympanoplasty (CAT)

• Lower facial ridge & break facial bridge

• Remove cholesteatoma & granulations from

• Mastoid cavity & E.A.C. become a single cavity

• Remove normal middle ear mucosa, T.M. remnant &

• Close Eustachian tube opening. No tympanoplasty

• Mastoid, E.A.C. & middle ear become single cavity.

 Recurrence after modified radical mastoidectomy

 Profound sensori-neural hearing loss (?)

2. Limited malignancy of middle ear

4. Osteomyelitis of temporal bone

2. Anterior tympanotomy: via tympano-meatal

3. Posterior tympanotomy: via facial recess

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